Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review.

BACKGROUND: Around 25% of patients who had a stroke do not present with typical 'face, arm, speech' symptoms at onset, and are challenging for emergency medical services (EMS) to identify. The aim of this systematic review was to identify the characteristics of acute stroke presentations associated with inaccurate EMS identification (false negatives). METHOD: We performed a systematic search of MEDLINE, EMBASE, CINAHL and PubMed from 1995 to August 2020 using key terms: stroke, EMS, paramedics, identification and assessment. Studies included: patients who had a stroke or patient records; ≥18 years; any stroke type; prehospital assessment undertaken by health professionals including paramedics or technicians; data reported on prehospital diagnostic accuracy and/or presenting symptoms. Data were extracted and study quality assessed by two researchers using the Quality Assessment of Diagnostic Accuracy Studies V.2 tool. RESULTS: Of 845 studies initially identified, 21 observational studies met the inclusion criteria. Of the 6934 stroke and Transient Ischaemic Attack patients included, there were 1774 (26%) false negative patients (range from 4 (2%) to 247 (52%)). Commonly documented symptoms in false negative cases were speech problems (n=107; 13%-28%), nausea/vomiting (n=94; 8%-38%), dizziness (n=86; 23%-27%), changes in mental status (n=51; 8%-25%) and visual disturbance/impairment (n=43; 13%-28%). CONCLUSION: Speech problems and posterior circulation symptoms were the most commonly documented symptoms among stroke presentations that were not correctly identified by EMS (false negatives). However, the addition of further symptoms to stroke screening tools requires valuation of subsequent sensitivity and specificity, training needs and possible overuse of high priority resources.

Stroke survivors' and carers' experiences of a systematic voiding programme to treat urinary incontinence after stroke.

AIMS AND OBJECTIVES: To explore the views and experiences of stroke survivors and carers about a systematic voiding programme for poststroke incontinence. BACKGROUND: Urinary incontinence after stroke is common and associated with poorer functional outcome. Structured assessment and management are potentially effective interventions, but it is important that there is a good understanding of stroke survivors' and carers' views of their acceptability and implementation. DESIGN: A qualitative study within a feasibility trial. METHODS: Sixteen participants (12 stroke survivors and four carers) were interviewed using a structured schedule shortly before discharge from one of six inpatient stroke units across six hospitals. Interviews were audio-recorded and transcribed verbatim, and thematic analysis was conducted. FINDINGS: Participants included seven male and five female stroke survivors (mean age 76 years) and four female carers (two wives and two daughters). Themes relating to the preliminary (assessment) phase of the programme were as follows: physical impact, psychological impact, beliefs about incontinence, and the assessment process itself. Main themes relating to the implementation of the programme included the following: timed voiding decisions, adapting the programme or the timed voiding schedule, and urinary incontinence management techniques. Participants felt that the programme helped them to re-establish a regular pattern of micturition and to regain autonomy. CONCLUSIONS: The effectiveness of a systematic voiding programme may partly lie in its educational component, challenging patients' and carers' assumptions that poststroke incontinence is inevitable. Individual adaptation of the programme and the ability to incorporate it alongside other aspects of care are likely to be key factors influencing implementation. RELEVANCE TO CLINICAL PRACTICE: Urinary incontinence is common after stroke. To maximise benefits from a systematic voiding programme, nurses should support stroke survivors to overturn erroneous beliefs, to participate in tailoring of the programme, and in self-management where appropriate.